Step 2 CK First Aid Rapid Practice Test

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A patient with sudden severe diffuse abdominal pain and peritoneal signs; AXR shows free air under the diaphragm. Which management?

Appendectomy Laparoscopic cholecystectomy Emergent laparotomy to repair perforated viscus Conservative management

Correct Answer:

Emergent laparotomy to repair perforated viscus

Explanation:

Pneumoperitoneum with peritoneal signs means a hollow viscus perforation causing peritonitis, a surgical emergency. The priority is source control, so an emergent laparotomy to locate and repair the perforation (with lavage and drainage as needed) is the appropriate management. Conservative approaches are unsuitable here because peritonitis from perforation carries high risk of sepsis. Broad-spectrum IV antibiotics and aggressive fluid resuscitation should be started, and the patient is kept NPO while preparing for surgery. While laparoscopy can be considered in select stable patients, the classic teaching for a patient with diffuse abdominal pain, peritoneal signs, and free intraperitoneal air is urgent open exploratory surgery to repair the perforation.

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